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Vehicle Registration ABN 61 760 960 480 Please Complete the White Sections, Print in Ink Using BLOCK Letters, Show Us Your Evidence of Identity, and Sign Below

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Vehicle Registration ABN 61 760 960 480 Please Complete the White Sections, Print in Ink Using BLOCK Letters, Show Us Your Evidence of Identity, and Sign Below Vehicle registration ABN 61 760 960 480 Please complete the white sections, print in ink using BLOCK letters, show us your evidence of identity, and sign below. The vehicle register records the identification details of each vehicle and the name and address of the registered operator of the vehicle. The register is not a register of vehicle ownership (title). What type of registration are you applying for? (please cross where applicable) .Dealers write reg’n no. then place VicRoads barcode here Light vehicle Recreation Bus Concessional Heavy vehicle Trailer Taxi Primary producer* Low emission vehicle Farm bike Hire Pensioner/DVA card (tailpipe CO2 of 120g/km Motorcycle Tow truck Health Care card* OFFICE USE ONLY or less) (office use) LAMS approved *You must complete the Date of issue D D M M Y Y Y Y Registration concessions form. Appointment no. Date of expiry D D M M Y Y Y Y Applicant details (the minimum age to register a light vehicle is 16 years, and 18 years to register a motorcycle or heavy vehicle) Surname or company name LMCT no. Vic licence/client no. First given name or ACN/ARBN Second given name Third initial (if any) Gender Health Care Card/ Date of birth D D M M Y Y Y Y Pensioner concession no. Residential (or company) address Postcode Postal address (if different from above) Postcode Garage address (VicRoads will only register vehicles garaged in Victoria) Postcode Mobile phone no. (or other if not applicable) Email Vehicle details (for a trailer, non-standard vehicle or vehicle over 4.5 tonnes GVM, also complete the Trailer and heavy vehicle specifications section overleaf) Please cross one circle per category below Year manufactured Y Y Y Y Previous registration number State Vehicle condition Transmission New Automatic Make Model Second-hand Manual Body type Colour Engine type Fuel type Piston (ie. has cylinders) Petrol Seating capacity Outside wheels Compliance plate date M M Y Y Y Y Rotary (ie. has rotors) Diesel Electric Gas (eg. LPG, CNG, LNG) VIN (or chassis number if no VIN) Other Multiple (eg. Petrol/Gas, Petrol/Electric) Engine number No. of cylinders/rotors Left hand drive Electric Yes No Hydrogen Tare (kg) Manufacturer GVM/GCM (kg) Engine cap. Hybrid RWC no. Tester licence no. Issue date D D M M Y Y Y Y Yes No OFFICE USE ONLY NEVDIS check printed? Yes Vehicle inspection required? Yes No If Yes, completed? Yes No Stolen check performed Vehicle inspector name Vehicle inspector signature Date Time Privacy statement Personal information VicRoads collects from you may be used by VicRoads as permitted by the Road Safety Act 1986 and the Marine Safety Act 2010. VicRoads may disclose personal information it collects from you to various organisations and persons as permitted by law, particularly by the Road Safety Act 1986. This includes the photograph and other information on your driver licence or learner permit being used for the purposes of biometric matching through the National Driver Licence Facial Recognition Solution for law enforcement, national security and other purposes. Personal information may be disclosed to contractors and agents of VicRoads, law enforcement agencies, other road and traffic authorities, the Transport Accident Commission, vehicle manufacturers (for safety recalls), road safety researchers, courts and other organisations or people authorised to use the personal information. Failure to provide the information may result in this form not being processed, or records not being properly maintained. For further information about our use of your personal information and your right of access to it, see VicRoads brochure Protecting your privacy or contact VicRoads on 13 11 71. Providing false and/or misleading information or documents is an offence under the Road Safety Act 1986 and/or Marine Safety Act 2010 and can result in you being fined or imprisoned. Any authority or approval, given as a result of you providing such information/documents, may be reversed and have no effect. Declaration By signing, the applicant or agent declares that: • the information in this form and related supporting documents is true, correct and complete, and the applicant understands the privacy statement • the applicant is entitled to be recorded as the registered operator because the applicant owns or is legally entitled to manage this vehicle • the applicant takes full responsibility for any loss, damage or claim caused by any false statement or misrepresentation made on this declaration, and the applicant indemnifies VicRoads and holds it harmless in respect of any such loss, damage or claim. Signature of applicant/agent Date D D M M Y Y Y Y Authority to act as agent Agent’s evidence of identity sighted (office use) This section must be completed if the vehicle is being registered by an agent. Full name of agent Agent’s licence no. Agent’s signature Date D D M M Y Y Y Y I authorise the person whose signature and details appear above to act as my agent for the registration of this vehicle. Applicant’s signature Date D D M M Y Y Y Y Post: VicRoads, GPO Box 1644, Melbourne, Victoria, 3001 Call: 13 11 71 (TTY 13 36 77, Speak and Listen 1300 555 727) Web: vicroads.vic.gov.au Vehicle registration OFFICE USE ONLY Evidence of identity (original documents only) Category A evidence Australian photo licence Australian birth certificate Passport Other (specify document type) Origin (state/country) Reference no. Date of expiry D D M M Y Y Y Y Category B evidence Document type Reference no. Evidence of residence + Document type Victorian residence declaration completed Signature of authorised officer Signature of manager (if required) Name of authorised officer Name of manager (if required) User ID Date D D M M Y Y Y Y Modified/Non-standard vehicles/Written-off vehicles Yes No Has the vehicle been modified? VASS approval certificate number Yes No Has a been supplied? VASS approval certificate VIV certificate number Yes No Has a VIV certificate been supplied? Yes No Is the vehicle to be conditionally registered? Approved operator group Conditional registration level Yes No Import documents VIA/CIN/045 number Trailer type (applies to heavy trailers only) What type of heavy trailer registration are you applying for? (please cross where applicable) Semi trailer Lead or middle trailer Dog trailer Pig trailer Dolly trailer Trailer and heavy vehicle specifications Number of axles Number of axles adjusted for charging GVM estimate (if manufacturer’s GVM unavailable)# Overall length (m) Overall width (m) Overall height (m) † Forward projection (m) (SPV only)^ Rear overhang (m) #Compliance plate on the vehicle must be checked. If there is no plate, attach evidence of the manufacturer’s GVM/GCM (eg. manufacturer’s letter or VASS Approval Certificate). † ^Special Purpose Vehicles only – steering wheel to the front of any projection. Centre line of rear axle or axle group to the end of the vehicle. If a vehicle exceeds the regulated mass and/or dimension limits, its eligibility for registration must be assessed by VicRoads. Where applicable, an overdimension or overmass permit may be required. Yes No Do the tyres meet the manufacturer’s GVM specification? Yes No Does the vehicle satisfy dimensional requirements for registration? Nominated configuration OFFICE USE ONLY (applies to all heavy motor vehicles except special purpose vehicles and buses, Payment please cross one circle only) Rate code HV road use fee# $ Rigid truck (no trailer) TAC code HV regulatory fee# $ SCV – Rigid truck and trailer (short combination truck) Up to 6 axles in combination and operating at Concession code# Registration fee $ 42.5 tonnes GVM or less OR TAC charge^ $ Prime mover and trailer (short combination prime mover) Dutiable value+ $ MCV – Rigid truck and trailer (medium combination truck) Number plate(s) $ More than 6 axles in combination or a truck/trailer 3 month registration Motor vehicle duty $ combination with 6 or less axles, operating over 6 month registration 42.5 tonnes GVM OR B double (medium combination Admin. fee $ prime mover) Part-year registration Other no. plate fees $ LCV – Rigid truck towing 2 trailers (long combination truck)* More than 6 axles OR Road train (long combination Total payable $ prime mover)* TAC charge^ includes GST of * You should check with VicRoads before operating these combinations in Victoria # Heavy vehicles only – those with GVM of more than 4.5 tonnes. + Dutiable value is the greater of purchase price or market value. as they may not be permitted. PTVH5190 STU02877 VRPIN01697 10.20 96677 Authorised and published by VicRoads, 60 Denmark Street, Kew, Victoria, 3101. ^ The GST amount shown for the TAC charge is the only GST included in the total payable. This document will be a Tax Invoice when payment is made..
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